New Zealanders Investigate Goitre Incidence In Nepal

Press, Volume CVI, Issue 31238, 9 December 1966, Page 22

New Zealanders Investigate Goitre Incidence In Nepal

r TO those of us who have been fortunate enough to take part in Himalayan mountaineering expeditions, the Sherpa people of Nepal appear as a cheerful and hardy people of exceptional vigour and strength. Even the Sherpa women can carry 60-pound loads to 19,000 feet and the men are renowned for their feats of endurance and courage at heights above 25,000 feet. In spite of this initial impression you don’t have to spend long in a Sherpa village before you realise it is by no means the full picture. Certainly our expedition Sherpas are remarkable for their strength and energy but they come from the healthiest 20 per cent of the community. The number of children who die in childbirth or in the early years of their lives is appalling; the smoky interiors of the Sherpa houses seem to encourage a host of diseases such as tuberculosis and various eye complaints and blindness; but more

than anything the iodinelacking thyroid glands produce a crop of ugly malformations and cretinism. Perhaps my best friend amongst the Sherpas is a fit and active man with a keen intellect, and his wife is a charming and attractive hostess. Yet their first child is a complete cretin—littli more than a cabbage—and the second child a deaf mute although with a sharp intelligence. Only the third child is normal in all respects (and somewhat pampered as a consequence). Most Common Complaint It is not surprising that a number of us who know and admire the Sherpas have wanted to do something about their most common complaint of goitre. It seemed an ideal arrangement to combine this programme with the building of a small hospital for the Sherpas. We were fortunate in working on this project with Dr. H. K. Ibbertson, M.R.C.P., F.R.A.C.P., a distinguished endocrinologist and physician-in-charge of the radio-isotope unit at Auckland Hospital. I will leave it to him to describe this important phase of our activities. Dr. Ibbertson writes:— Forty years ago a pioneer student of endemic goitre called Marine stated that simple goitre is the easiest of all known diseases to prevent.

This is the third dispatch from Sir Edmund Uillary’e Sherpa Hotpital Expedition. At much the same time a British Indian Army doctor called McCarrison made a study of goitre in the Himalayan people of northern India. Causes of Goitre He discovered an incredibly high percentage of severe goitre, cretinism, and mental deficiency and his researches showed how important in causing these conditions were deficiency of iodine, poor sanitation, and goitre producing foodstuffs. In spite of his remarkable descriptions and the subsequent observations of many climbing expeditions, little attempt was made to do anything about this unusual occurrence of goitre until quite recently. In the years after 1960 Sir Edmund Hillary established a number of schools for Sherpa children in the Khumbu region of the Nepal Himalaya. In 1964 a limited iodisation programme was introduced in three of these schools. It was a simple scheme but it worked well—every week the children lined up , to receive a tablet of iodine. In the last few months it has been possible to measure the results of this scheme and it has clearly had a substantial effect on the children involved. Expensive Research This year Sir Edmund Hillary is back in Nepal with the main objective of building a hospital for the Sherpas of the Khumbu. Combined with the hospital building programme we are carrying out extensive research into the severe endemic goitre in the area. We have a five-man research team of four doctors and one physicist Our task is not only to investigate the incidence and cause of the goitre but also to institute a treatment programme which will be supervised subsequently by the doctor to be permanently stationed at the hospital. Finance has been provided by the International Atomic Energy Agency and by the Wellcome Trust of London and our team is supplied with the latest electronic radioisotope counting equipment, portable X-ray and electrocardiograph machines, and a great deal of valuable laboratory equipment All of this equipment was flown into the small airfield at Lukla on October 3 and carried by porters on the two-day march up the Dudh Kosi valley to Khumjung at 13,000 feet. This primitive community has a dramatic and lovely setting and here we set up a modern radioisotope laboratory in two large tents. Routine Established Cross the valley is the great summit Tamserku (21,700 feet) and towering over us is Khumbila, the sacred mountain, whose god no doubt frowns on our unusual activities. We soon established a sound routine at Khumjung. Undisturbed by the busy noise of hammers at the new hospital near by, we have been investigating 20 to 60 Sherpas a day. Each Sherpa is interviewed and a detailed and often involved family history is extracted. Then a code number is allocated and a photograph is taken. The photograph is necessary for identification purposes as there are relatively few Sherpa names and duplication often occurs. All this activity is regarded with tolerant amusement by the Sherpas who have long since decided that the Sahibs have some very strange customs. A small tracer dose of radioactive iodine is given to each patient by mouth or injection. This radio-active iodine is taken up by the thyroid gland according to its needs and if the patient is very short on iodine, as most of the Sherpas are, then a high percentage of the radio-active dose is concentrated into the thyroid. Thyroid Function

We can measure this by the recording bead of the radioactivity counter at the front of the patient’s neck. We also count the radioactivity in blood and urine samples and all these results together provide a picture of the thyroid function. The thyroid gland controls body growth, development and function, so we make careful measurements of body proportions, take X-rays of bone growth, electrocardiographs, and measurements of muscle reflex activity. Such methods enable us to analyse any abnormalities present and estimate their influence on the body as a whole. Each day brings a fascinating array of patients—elderly women with enormous goitres who chant prayers and whirl prayer wheels while having their tests, and deaf mute children who gaze in wonder at the blinking lights of the counting equipment and communicate with each other in their own sign language. Hearing For First Time

Several of these children have to their delight been able to hear for the first time by simply placing the earpiece of a transistor radio in their ears. Even more tragic are the pathetic cretin children whose “slow sweet smile** reflects the permanent mental and physical retardation which has resulted from severe iodine deficiency during the mother’s pregnancy. Many difficulties have been

overcome. The extreme temperature variations at this altitude affect the delicate counting equipment; plasma samples freeze in t|ie labora-

tory tent while awaiting processing; and the Sherpa people, cheerful in spite of their many problems, have little idea of time by Western standards. Chasing Patients There is not infrequently an undignified scramble up a mountain to capture a prize patient who has wandered off to attend his yaks in the middle of an experiment Like people everywhere they are reluctant to part with blood specimens, so essential to these detailed studies. In spite of this reluctance, many hundreds of samples have been taken. Our Sherpas collect snow from the surrounding peaks and we mix this with salt and freeze the specimens to await air freighting to New Zealand where more detailed analysis will be performed. Final results must await this analysis, but many points of interest have already emerged. The incidence of goitre has been shown to be as high as 98 per cent in some villages and the majority of children are affeoted. Severe Deficiency It is gratifying to find that the schoolchildren have a much lower incidence due to their weekly iodine pill, but radio-iodine studies indicate such a severe degree of iodine deficiency that an increase in dosage will be necessary. Of particular interest is a pair of identical twin girls, one of whom has been attending Khumjung school and receiving iodine for one year. In contrast to her goitrous and lethargic sister she is active and bright eyed and has only a small goitre. lodine has corrected the lack of thyroid hormone which so insidiously retards body functions. All of these effects are particularly obvious in the village of Phortse, higher up the Dudh Kosi valley toward Mt Everest. Ten days ago we set up another laboratory in a Sherpa’s house at Phortse. Transport Problem Getting our 35 loads to Phortse over very narrow and steep trails was something of a problem in itself. Our generator and motor weighed over 300 pounds and we decided to move it in one piece to save the trouble of dismantling. Carrying it up the track was

bad enough for our Sherpas but descending the precipitous slopes toward the river was much worse. Ed Hillary and I hung on to the rope behind as anchormen and slipped and slithered our way down trying to check the party’s speed by clasping every tuft of grass or stunted shrub. We expected at any moment to be dragged over the cliffs into the abyss. We have agreed to dismantle the generator for the return journey. Of the population of 233 people in Phortse there are 20 obvious cretins and a similar number of deaf mutes. At least 50 per cent of the population are slow in their speech, thought and move-

ment with hearing defects attributable to the lack of thyroid hormone. Community Burden Such individuals, although well integrated, impose a social and economic burden which this poor community can ill afford. This deplorable situation is entirely preventable and to some degree reversible. Whatever the causes involved, the supply of a few milligrams of iodine can dramatically alter the lives of these people. With this in mind a controlled programme of prophylaxis and treatment with iodine and thyroid hormone tablets has begun. The iodising of salt is not easily achieved in this mountainous

area with multiple sources of supply. Australian workers in New Guinea have demonstrated the value of iodised oil injections as a source of iodine. lodine is released in the body from these injections for at least three years and is effective both as a preventive and to shrink existing goitres. We are now giving these virtually painless injections to hundreds of people in this area. Our work is still only in its preliminary stages but already sufficient benefit has been obtained to confirm the words of Marine . . . “that goitre and its accompaniments can be excluded from the list of human diseases as soon as society determines to make the effort.”